Blackwell Science, LtdOxford, UK

PCN
Psychiatric and Clinical Neurosciences
1323-13162003 Blackwell Science Pty Ltd
573June 2003
1125
Phenomenology of hallucinations
G. Singh
et al.
10.1046/j.1323-1316.2003.01125.x
Original Article333336BEES SGML

Psychiatry and Clinical Neurosciences (2003), 57, 333–336

Short Communication
Phenomenology of hallucinations: A factor
analytic approach
GAGANDEEP SINGH, MD, PRATAP SHARAN, MD AND
PARMANAND KULHARA, MD, FRCP
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Abstract The present study was carried out with the aim of obtaining a factor analytic solution of parameters
of hallucinations in schizophrenia. Seventy-five chronic hallucinating schizophrenic patients were
assessed on the Phenomenology of Hallucinations Scale and Brief Psychiatric Rating Scale. A
factor analytic solution was obtained by principal component analysis using varimax rotation. Two
factors, ‘reality of hallucinatory perception’ and ‘immersion in hallucination’, were obtained.
Findings are discussed in relation to existing literature.

Key words hallucinations, phenomenology.

INTRODUCTION istics of hallucinations.8 These were (i) emotional char-

acteristics (i.e. distress-negative content); (ii) physical
Traditionally, hallucinations have been described to
characteristics (i.e. frequency, location, loudness etc.);
have ‘form’ and ‘content’ elements. ‘Form’ is described
and (iii) cognitive interpretation factor (i.e. beliefs
as those components of hallucinations that reflect the
regarding the origin and attribution of control). The
perception of objective reality in the hallucinations. On
factors accounted for 57.4% of total variance.
the other hand, ‘content’ is said to consist of elements
Phenomenology of Hallucinations is the first and
that reflect the patient’s life experiences synthesized
still one of the most widely used scales to assess vari-
through his/her memory.1 This dichotomy has been
ous parameters of hallucinations.3 Many of the other
criticized on account of its failure to differentiate
scales (related to hallucinations)4–6 are derived from
between the two when grammatical constructs were
this scale. We carried out a factor analysis on items
considered.2
comprising this scale after administering it to a group
Assessment tools focused on phenomenology of hal-
of 75 chronic stable hallucinating patients with schizo-
lucinations are limited in number and carry moderate
phrenia, with the aim of examining whether a similar
reliability and validity.3–8 Multidimensional assessment
factor structure as the one obtained in the study by
of psychotic symptoms such as delusions or hallucina-
Haddock et al.8 would emerge for hallucinations in a
tion is important not only for detailed exploration, but
study differing in terms of instruments and patient
also for assessment of broader outcome.8
characteristics.
Attempts have been made to yield factor solutions
of various characteristics of hallucinations using empir-
ical research. Haddock et al., while assessing the reli- METHODS
ability and validity of Psychotic Symptoms Rating
The sample consisted of 75 patients selected from the
Scale (PSYRS) on 71 patients with schizophrenia,
patient population attending the Psychiatry Outpatient
arrived at a three-factor solution for various character-
Department of Postgraduate Institute of Medical Edu-
cation and Research, Chandigarh (PGIMER). The
inclusion criteria were (i) a definite diagnosis of schizo-
Correspondence address: Dr Pratap Sharan, Department of Psychi- phrenia according to International Classification of
atry, Postgraduate Institute of Medical Education and Research,
Chandigarh 160012, India. Email: pratapsharan@yahoo.com
Diseases (10th revision; ICD-10) diagnostic guide-
Received 22 July 2002; revised 26 November 2002; accepted 1 lines;9 (ii) total duration of illness of more than 2 years;
December 2002. and (iii) reported presence of hallucinations (in any
Short Communication
334
modality) in the last 3 months (75% of patients had
hallucinations on the day of examination). Patients
with concomitant major chronic illness, organic brain
disease, and substance abuse were excluded from the
study.
Written informed consent was taken from the
patient or an adult relative in cases where the patient
was considered to be unfit for providing such a consent.
The patient and a relative were interviewed to elicit
information regarding sociodemographic profile, diag-
nosis, duration of illness, duration of drug treatment
and mean daily dose of neuroleptics (in chlorprom-
azine equivalents).
All patients were assessed on Phenomenology of
Hallucinations Scale,3 which is a semistructured inter-
view consisting of 15 items, each of which is scored
from 1 to 3. The scale measures various parameters of
hallucinations, namely extent (frequency and dura-
tion), location, reality (current and past), sensory
intensity, constancy, overt behavior, control, time,
causal, experience shared, content–affect, content–
verb and content–noun. Patients were also assessed on
Brief Psychiatric Rating Scale.10
The symptom interrelationships were studied by
principal component factor analysis. The factors were
subjected to a varimax rotation. Item loading with
absolute values >0.4 were used to describe the factors.
Pearson’s product moment correlations and Stu-
dent’s t-tests were calculated to examine the relation-
ship between variables and factors.
RESULTS
Forty-nine (65.3%) patients were male. Forty-eight
(64.0%) patients had paranoid schizophrenia while 27
(36%) belonged to non-paranoid schizophrenia cate-
G. Singh et al.
gories. Mean duration of illness was 128.73 ± 90.31
months. The mean Brief Psychiatric Rating Scale
(BPRS) score at the time of assessment was
44.66 ± 7.66. Patients were receiving a mean of
483.33 ± 312.56 mg of neuroleptics in chlorpromazine
equivalents per day at the time of assessment. All
patients were receiving typical neuroleptics. While 55
(73%) patients had never been hospitalized, another
20 patients (27%) had been hospitalized at least once
in their lifetime.
Five eigenvalues greater than unity were obtained.
However, as shown in Fig. 1 on analyzing the scree plot,
the number of factors obtained was two.
The two factors captured 30% of the variance. Vari-
max rotation was carried out on 2–5 factors and the
results were interpreted in terms of clinical relevance.
The rotated two-factor solution was assessed to be the
best in clinical sense. Overall nine items of the scale
had loading (on either factor) with a value >0.4. Factor
I consisted of items on reality (current), reality (past)
and sensory intensity. Factor II consisted of item on
frequency, duration, overt behavior, control, time, and
content–affect.
The items related to locality, constancy, causal, expe-
rience shared, content–noun and content–verb did not
load on either of the two factors.
Correlational analysis of these factors with age and
other clinical characteristics revealed that factor I cor-
related positively with mean dose of antipsychotics
received (in chlorpromazine equivalents; r = 0.31;
P < 0.05) and BPRS score (r = 0.40; P < 0.001) No sig-
nificant correlation was observed with age, duration of
illness and duration of treatment. As shown in Table 1,
this factor did not show any difference in groups
defined by gender, number of hospitalizations or sub-
type of schizophrenia.
Figure 1. Scree plot of eigen value.
Phenomenology of hallucinations 335

Table 1. Comparison of factors I and II overt behavior, time and affect. It reflects the percep-
tual–affective–behavioral immersion of the patient in
Variables Mean ± SD Probability the hallucinatory experience. Hence, the factor was
named ‘immersion in hallucination’. This factor too
Gender
had a positive correlation with BPRS score, indicating
Factor I
its contribution to total psychopathology.
Male (n = 49) 6.08 (2.05) 0.45
Female (n = 26) 6.30 (2.05) (NS) The factor structure obtained in the present study is
Factor II quite different from that of the study by Haddock
Male (n = 49) 13.20 (1.93) -0.39 et al.8 In our study the ‘immersion in hallucination’ fac-
Female (n = 26) 13.38 (1.81) (NS) tor had loadings of items related to the first two factors
No. hospitalizations: in their study: ‘emotional characteristics’ (e.g. distress)
Factor I and ‘physical characteristics’ (e.g. frequency); while
Nil (n = 55) 6.01(2.11) -0.99 our ‘reality of hallucinatory perception’ factor had
≥1 (n = 20) 6.55 (1.84) (NS) some loadings for their ‘physical characteristics’ factor
Factor II (e.g. loudness), but it was clearly different from the
Nil (n = 55) 13.23 (1.94) -0.23
latter in terms of additional items that were present
≥1 (n = 20) 13.35 (1.75) (NS)
(i.e. reality) and items that were absent (e.g. location,
Subtype of schizophrenia
Factor I frequency etc.). The third factor, ‘cognitive interpreta-
Paranoid (n = 48) 6.24(2.11) 0.19 tion’ in the Haddock et al. study8 was not represented
Non-paranoid (n = 27) 6.14(1.98) (NS) at all in the present study. The differences in the results
Factor II in the two studies could be due to differences in
Paranoid (n = 48) 13.33 (2.10) 0.08 patient characteristics. In the study by Haddock et al.
Non-paranoid (n = 27) 13.14 (1.59) (NS) 73% of patients had a diagnosis of schizophrenia,
while 27% belonged to the category of schizoaffective
NS, not significant. disorders.8 In the present study all patients belonged to
the category of schizophrenia. Mean duration of ill-
ness in the present study (128.73 ± 90.31 months) was
Factor II had a positive correlation with BPRS score less than that in the study by Haddock et al. (mean:
(r = 0.289; P < 0.05). Age, duration of illness, duration 157.0 ± 114 months).8 Patients were recruited from the
of treatment, and mean dose of antipsychotics did not outpatient clinic of a tertiary care center in the present
have any significant correlation with factor II. As study, while in the study conducted by Haddock et al.
shown in Table 1, this factor also did not show any patients were selected from a training programme and
difference in groups defined by gender, number of hos- community.8 In the study conducted by Haddock et al.8
pitalizations or subtype of schizophrenia. patients were assessed on Psychiatric Rating Scale
(PSYRATS) to determine dimensions of both delu-
sions and hallucinations. In PSYRATS, hallucinations
DISCUSSION
are assessed on a 0–4 scale on dimensions such as fre-
The present study was aimed at obtaining an empirical quency, duration, location, belief about origin of
grouping of characteristics of hallucinations, and at voices, amount of negative content, degree of negative
exploring their external correlates. content, amount of distress, intensity of distress, dis-
The first factor consisted of three characteristics ruption of life and controllability. Median severity
related to hallucinations: reality (current), reality score (sum of all the items) in that study was found to
(past) and sensory intensity. This factor was labeled be 28. In the present study the ‘parameter of halluci-
‘reality of hallucinatory perception’. nation scale’ has no provision for calculating severity
This factor was observed to have a positive correla- of hallucinations. However, the median of sum total of
tion with total psychopathology (BPRS). Earlier stud- all items was found to be 33. Due to the differences of
ies have also noted greater psychopathology in patients the items content and scoring pattern, the two values
who regard hallucinations as ‘real’.11,12 The association cannot be compared.
between severity of psychopathology and the ‘reality The differences in the two factor analytic studies on
of hallucinatory perception’ may explain its positive hallucinations (Haddock et al.8 and the present study)
correlation with the mean dose of antipsychotics and the relatively low variance explained (30% in the
received by the patients. present study) suggest that the final word on dimen-
The second factor had significant loadings of six sions of hallucinations is yet to be said. Clearly, more
characteristics, namely frequency, durations, constancy, studies are required before useful sets of dimensions
336
that can help in assessment of broader outcome are
obtained.
To summarize, an attempt was made to find a factor
analytic solution of parameters of hallucinations in 75
chronic hallucinating schizophrenic patients. Principal
component analysis using varimax rotation yielded
two factors: ‘reality of hallucinatory perception’ and
‘immersion in hallucination’. These factors captured
30% of the total variance. The factors did not show any
significant correlation with sociodemographic (age,
gender) or clinical variables (duration of illness, dura-
tion of treatment, number of hospitalizations and
subtype of schizophrenia). The factor ‘reality of hallu-
cinatory perception’ correlated positively with total
psychopathology and mean dose of antipsychotics
received. The factor ‘immersion in hallucination’ cor-
related positively with total psychopathology.
The study had some important limitations. First, the
definition of ‘current’ hallucination was broad (3
months). Second, the ‘phenomenology of hallucina-
tion’ scale has not been validated for Indian patients.
Third, selection of chronic outpatients being treated at
a tertiary care center limits the generalizability of find-
ings to the population of schizophrenic subjects, par-
ticularly to those who are acutely ill.
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